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General NPI Number Information
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NPI Number | 1710162862
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Entity Type | Organization
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Legal Business Name | WISE BEHAVIORAL HEALTH SERVICES LTD
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Dates
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Enumeration Date | 01/08/2008
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Last Update Date | 01/08/2008
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Provider Practice Location Address
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Address Line | 9012 S CRANDON AVE
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City | CHICAGO
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State | IL
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Zip | 60617-3807
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Country | US
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Telephone | 773-375-8741
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Fax | 773-375-8748
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Provider Business Mailing Address
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Address Line | 9012 S CRANDON AVE
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City | CHICAGO
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State | IL
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Zip | 60617-3807
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Country | US
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Telephone | 773-375-8741
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Fax | 773-375-8748
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. CHARLES TRIPP
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Credential |
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Telephone | 773-510-6165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State | IL
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